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First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Have you used chemical hair relaxers/straighteners?*

Yes

No

What chemical hair relaxers/straighteners have you used?*

L'Oreal Dark and Lovely

L'Oreal Optimum

Soft & Beautiful

Motions

Just for Me

Olive Oil Girls

Other

How often have you used chemical hair relaxers/straighteners?*

Have you been diagnosed with Uterine Cancer, Ovarian Cancer, or Endometrial Cancer after using Hair Relaxers?*

Yes

No

What year were you diagnosed?*

When would be a good time to call you?

Central Time

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